PROOFS OF DEATH-CLAIMANT'S STATEMENT - Pioneer …

PROOFS OF DEATH-CLAIMANT'S STATEMENT

INSURING COMPANY (Please check one):

American-Amicable Life Insurance Company of Texas ? Email: Claims@ IA American Life Insurance Company ? Email: Claims@IAAmerican- Industrial Alliance Insurance and Financial Services Inc. ? Email: Claims@IAPlife- Occidental Life Insurance Company of North Carolina ? Email: Claims@ Pioneer American Insurance Company ? Email: Claims@ Pioneer Security Life Insurance Company ? Email: Claims@

P.O. Box 2549 ? Waco, TX 76702-2549 ? 800-736-7311

By furnishing forms and investigating the claim, the company does not admit that there is any insurance in force and does not waive any of its rights or defenses.

1. Policy Numbers:__________________________________________________ Amounts:______________________________________________ 2. Deceased's name in full:_________________________________________________________________ Marital Status:_____________________ 3. Residence at death: Street:____________________________ City:__________________________State:_______________ Zip:_________ 4. Usual Occupation (not just Retired): ____________________________________________________________________________________ 5. a. Date of deceased's birth: _________________________________________ b. Place of birth:___________________________________ 6. a. Date of death: ___________________________________________________ b. Place of death:____________________________________ c. Cause of death: ____________________________________________________________________________________________________

Note: Complete questions 7 through 11 only if policy has been in force less than 2 years and / or accidental benefits are claimed.

7. Date deceased first complained of, or gave other indications of his / her last illness:_____________________________________________

8. When did deceased first consult a physician for his / her last illness?_______________________________________________________________

9. On what date did deceased last attend to his / her usual work?___________________________________________________________

10. Give names and address of all physicians who attended deceased during the last five years prior thereto:

Names

Addresses

Date of Attendance

Disease or Condition

11. In what other companies, and for what amounts, was the life of the deceased insured under accident and / or life policies? ___________________________________________________________________________________________________________________

12. I hereby certify that the policy of insurance for the listed policy has been (If policy is enclosed we must have original; a photocopy is not acceptable) 13. Taxpayer I.D. Information:

ENCLOSED

LOST

DESTROYED

Enter the claimant's taxpayer identification number BENEFICIARY / CLAIMANT'S SS. NO. in the appropriate box. For most individuals this is your social security number

OR TAX I.D. NO.

CERTIFICATION - Under penalties of perjury I certify that (1) The number shown on this form is my correct Taxpayer Identification Number (or I am waiting for a number to be issued to me) and (2) I am not subject to backup withholding either because I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as

a result of a failure to report at interest or dividends or the IRS has notified me that I am no longer subject to backup withholding.

PLEASE CLAIMANT'S SIGNATURE SIGN HERE

DATE

14. Dated at______________________________________________this_______________day of_____________________________, 20______.

City & State

15. Claimant's Signature __________________________________________Date of Birth_______________Relationship_____________________

Claimant's Printed Name ___________________________________________________

16. Claimant's Mailing Address____________________________________________________________________________________________

Street or P.O. Box

_________________________________________________________________________ Daytime Phone No. ___________________________

City

State

Zip

17.Witness to Signature______________________________________________________ (Does not need to be notarized)

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Important Notice

In some states we are required to advise you of the following: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application containing a false or deceptive statement may be guilty of insurance fraud.

Please review the appropriate fraud warning relevant to the state that you reside in prior to submitting your claim.

Alabama ? Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.

Alaska ? Any person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.

Arizona ? "For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties."

Arkansas ? Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

California ? For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Colorado ? It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.

District of Columbia ? Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Florida ?Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Idaho ? Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.

Indiana ? A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.

Kentucky ? Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

Louisiana ? Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Maine ? It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties my include imprisonment, fines, or a denial of insurance benefits.

Maryland ? "Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or b enefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison."

Massachusetts ? Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in state prison.

Minnesota ? A person files a claim with intent to defraud, or helps commit a fraud against an insurer, is guilty of a crime.

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New Hampshire ? Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution or punishment for insurance fraud, as provided in RSA 638:20.

New Jersey ? Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

New Mexico ? Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

New York - GENERAL: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation

Ohio ? Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Oklahoma ? WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete, or misleading information is guilty of a felony.

Oregon ? Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact thereto, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties.

Pennsylvania ? Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Puerto Rico ? Any person who, knowingly and with the intent to defraud, presents false information in an insurance request form, or who presents, helps or has presented a fraudulent claim for the payment of a loss or other benefit, presents more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine no less than five thousand (5,000) dollars nor more than ten thousand (10,000) dollars, or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to a minimum of two (2) years.

Rhode Island ? Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Tennessee ? It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

Texas ? Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Utah ? Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison. Utah Workers Compensation claims only

Virginia ? It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Washington ? It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

West Virginia ? Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

In All Other States ? Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer submits an application containing a false or deceptive statement may be guilty of insurance fraud.

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